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AIMS: To assess the practical implementation of international guidelines and their impact on syncope management in a 500-bed general hospital. PATIENTS AND METHODS: Three groups of 63 consecutive patients admitted for syncope to the emergency care unit (ECU) were studied: group 1, before the guidelines delivered to the practitioners, group 2 immediately after the diffusion of guidelines and group 3, one year later. The study evaluates the mean duration of stay (MDS) and the relevance of the diagnostic strategy. RESULTS: In group 1 compared to group 2, MDS were respectively 6.8±5.5 and 5.4±2.8 days (P=0.07) and the unexplained syncope number respectively 22% and 24% (P=0.8). The search of orthostatic hypotension became more systematic (13% versus 86% in group 1 and 2 respectively, P<0.001). The agreement (kappa coefficient) between initial and final diagnostic increased in 0.34 to 0.44. One year later MDS in group 3 was 7.1±4.7 days (P=0.8 versus group 1 and P=0.015 versus group 2) with only 6.3% systematic search for orthostatic hypotension (P<0.001). CONCLUSIONS: Guidelines optimize the syncope management in the ECU and the agreement between the emergency and discharge diagnostic without change of unexplained syncope and. MDS tend to be shorter when guidelines are actively implemented. Nevertheless, the positive impact of guidelines implementation is of limited duration.

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BACKGROUND: Intravenous almitrine, which augments hypoxic pulmonary vasoconstriction, is used for short-term improvement of arterial oxygenation. However, recent research has suggested a potentially harmful effect on lactate metabolism and hepatic function. METHODS: Arterial oxygenation, hemodynamic parameters, plasma lactate, and hepatic function were monitored prospectively in 25 patients with acute lung injury (defined as a ratio of arterial oxygen pressure to inspiratory oxygen fraction < or = 150 mmHg) who where treated with intravenous almitrine. In 21 of 25 patients, acute lung injury was related to primary lung lesions, including pneumonia, postcardiosurgical atelectasis, and lung contusions. RESULTS: Intravenous almitrine increased the ratio of arterial oxygen pressure to inspiratory oxygen fraction from 93 +/- 33 mmHg to 207 +/- 107 mmHg (mean +/- SD). In eight patients (three men), the plasma lactate concentration increased by an average of +3.5 +/- 1.8 mM, and the pH and bicarbonate concentration both decreased during the first 24 h of treatment. In this group of patients, the total bilirubin concentration was elevated before almitrine administration, and the results of other hepatic function tests, such as aspartate aminotransferase, alanine aminotransferase, and prothrombin time, were altered by almitrine administration. Therefore, intravenous almitrine was discontinued. Lactic acidosis and hepatic dysfunction improved. In the other 17 patients (14 men), the plasma lactate concentration and the hepatic function tests remained unaltered during intravenous almitrine therapy for > 60 h. Univariate and multivariate analyses revealed that an abnormal plasma concentration of total bilirubin before almitrine administration and female gender were the two factors significantly linked with lactic acidosis during almitrine infusion. CONCLUSIONS: This study confirms that intravenous almitrine greatly improves arterial oxygenation in patients with acute lung injury but may also induce lactic acidosis and hepatic dysfunction. The coexistence of lactic acidosis and hepatic dysfunction in the same patients strongly suggests that the liver is the primary source of intravenous almitrine-induced lactic acidosis.

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Septic shock remains an acute condition with a bad prognosis and a high mortality rate. This could be related to our incomplete understanding of the pathophysiological mechanisms involved, especially in the immunological field. Recently, several studies have stressed the key role of cytokines. Amongst these, the tumour necrosis factor (TNF) seems to be the most important. This peptide is a hormone secreted by monocytes and macrophages under the effect of various stimuli such as lipopolysaccharides or endotoxin. Giving TNF mimicks the clinical and biological patterns of septic shock. Moreover, high concentrations of TNF have been found in patients suffering from septic shock. Pretreatment with monoclonal antibodies against TNF prevents the occurrence of septic shock after endotoxin administration. TNF acts directly via ubiquitous specific receptors; this probably explains its diffuse activity. The therapeutic implications of these recent advances are not clear. It is not known, for the moment, whether TNF secretion is beneficial or deleterious for the patient.

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Experimental hepatic resections were performed with a Nd YAG laser in 32 New-Zealand rabbits. The beam was simply transmitted by a quartz fiber of 4 degrees 2 and 8 degrees in divergence for the full angle, without any focalization. Section was possible at a power output superior to 20 W requiring short cutting time. Complete hemostasis was obtained as long as the diameter of encountered vessels did not exceed 4,5 mm. Immediately after resection the parenchyma was covered by an ischemic layer varying from 2 to 8 mm. Its thickness rapidly increased to high levels whenever the power output exceeded 40 W or when hepatic pedicle was clamped. Healing process was installed at day 30. There was no hemorrhagic, biliary or septic complication. Eleven animals were alive eight months after. Histological examination revealed four layers: a first one of carbonization, a second of condensed cells, a third of edema presenting disruption of sinusoids, and a fourth one composed of progressively normal tissue. Peripherical veins presented thrombosis of their blood content and coagulative necrosis of their wall while bile canaliculi were preserved. Fibrosis appeared in the edematous layer the 10th day and was completely formed at day 30. Electron microscopic examination revealed shadowy cells embedded in the condensed layer and mitochondrial alteration in the edematous layer. The 15th day foci of cell regenerations were registered. High levels of SGOT, SGPT and LDH (fractions IV and V) were observed immediately after resection.(ABSTRACT TRUNCATED AT 250 WORDS)

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Two properties of the laser beam can be used in medicine: coagulating and sectionning. The possibility for the beam to reach its target through an optic fibre, adaptable to the broncho-fibroscope, enables its use in bronchology. Two patients with a malignant tracheo-bronchial tumour received this treatment. Results were encouraging. Some practical applications are proposed.

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In 18 subjects undergoing aorto-bifemoral by-pass, pre-operative isovalaemic hemodilution was carried out (using a dextran of molecular weight 60,000) at the same time as venous section of a mean value of 1087 ml reducing the hematocrit to 0.30. The following were studied before, immediately after and 24 hours after hemodilution: blood viscosity (at variable shearing rates), oncotic pressure, sedimentation rate, clotting factors, plasma electrolytes. These results showed that at the end of hemodilution, oncotic pressure was maintained and even increased despite the fall in blood protein levels, with also a decrease in blood viscosity, a tendency to dynamic hypocoagulability (thrombocytopenia, fall in fibrinogen and increase in cephalin kaolin time and Quinck time) without any increase in lytic activity. 24 hours later, these parameters tended to return to normal. Discussion on the basis of a study carried out in vitro, seeks to demonstrate which of these changes were related to the dextran molecule and which were related to the hemodilution.

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The neuroleptic drugs used in anesthetics belong to the group of phenothiazines or butyrophenones. The endocrine response to their intravenous administration is still ill-known and usually only concerns the association of anesthetics and neuroleptics. However, as far as the catecholamines are concerned, it is known that neuroleptic drugs do not prevent either their secretion nor their liberation but, depending on their dosage, they block the dopaminergic receptors and the alpha-receptors and induce disturbances in the metabolism of the mono-amines. The injection of neuroleptics associated with analgesics, raises the blood levels of catecholamines, does not induce a rise in ACTH and cortisol levels in the absence of stress, but does not totally prevent their rise in cases of aggression. As far as growth hormone is concerned, the effects are variable depending on the association studied. There is a rise with droperidol + pethidine or pentazocine, no change with chloroprotixene-dextromoramide. In both cases, the blood sugar rises. As far as STH, or growth hormone, free fatty acids and insulin are concerned, one may note a rise with associations containing droperidol even in the absence of any stress and stability with a mixture of chlorprotixene and dextromoramide. With none of these well known associations was there any variation either in levels of pituitary thyreo-stimulin, nor in thyroxine levels. Testosterone becomes reduced with the association of droperidol + analgesics but this effect does not seem to be specific to droperidol. These responses are frequently disturbed in case of additional stress.

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In 14 patients anaesthetized before undergoing an orthopedic surgical intervention, the variations induced by anaesthesia in the 17 hydroxycorticosterone rate, catecholamine, somatotropic hormone (STH), insulin, glycemia, free fatty acids and thyrotropin (TSH), all these variations were studied before the surgery. The patients were divided into 2 groups of 7, the first one being anaesthestized by chlorprothixene dextromoramide Neurolept-Analgesia and the second one by Alfadione Fentanyl venous anaesthesia.

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